HEALTH: Aging; Finally, Doctors Ask if Brutal Falls Need Be a Fact of Life for the Elderly

Scientists have embarked on major efforts to determine why so many elderly people suffer devastating falls and to identify medical and social measures that can curb the disastrous toll.

While a fall is usually harmless for children and young adults, it can carry a heavy penalty for the elderly. Each year, it is estimated, more than 200,000 Americans over the age of 65 fracture their hips in falls, and 20,000 to 30,000 die of complications. Fewer than than 25 percent of the survivors ever regain their previous mobility, and experts say the cost of direct care is $7 billion or more a year.

Until recently the falls were considered an intrinsic part of aging, like gray hair or wrinkles. Nothing much could be done to ward them off, or so it was thought. But in the last five years medical experts have dramatically altered their approach to falls, and far more resources have been devoted to seeking causes and preventive measures.

The new research, which has not yet conclusively identified the causes, covers a variety of topics, including brain changes, cardiovascular conditions, degeneration of bone or muscle, and the role of drugs, living habits and home environment. Taken for Granted

Commenting on the many questions now being raised in research centers around the country, Dr. T. Frank Williams, director of the National Institute on Aging, said: ''None of them were even looked at three years ago. Nobody had begun to look at falls as a major problem. We just used to assume it was old age and it was too bad, but old people fell.''

At the Hebrew Rehabilitation Center for Aged in Boston, Dr. Louis Lipsitz is measuring how everyday activities like eating meals, changing posture and taking medication cause the sudden declines in blood pressure that can provoke fainting and falling.

In South Miami Beach, the Dade County Health Department has been studying the health histories and living situations of people taken to emergency rooms because of falls to see what alterations in the home ought to be made.

In San Francisco, Dr. Steven Cummings and Dr. Michael Nevitt, both assistant professors of medicine and epidemiology at the University of California, are trying to define risk factors by following 325 elderly patients who have fallen at least once.

One of the studies being watched with special interest is by Dr. Leslie Wolfson, a professor of neurology at the Albert Einstein College of Medicine in the Bronx.

His work, done with a physical therapist and a nurse, was conducted in two phases. From 1982 to 1985, he studied 50 extremely frail residents of Morningside House, a nursing home in the northeast Bronx. In 1986 he began working with 200 healthy people from 70 to 90 years old who live on their own in the neighborhood.

He tested the nursing home patients for strength and equilibrium on a special balance platform. The platform is basically a booth with a floor that can be moved and tilted. The patient, prevented from actually falling by support straps, faces an abstract horizon that can be changed as part of the test.

Dr. Wolfson determined that balance is dependent on the ability to coordinate the responses of the eyes with sensations detected in the vestibular apparatus of the inner ear and by the feet. But he said the key question remained, ''Where in the reflex loop does the breakdown occur?''

With computerized X-rays, or CAT scans, of the nursing home patients, he detected marked changes in the white matter under the cortex of the brain.

''The white matter contains the cables that go from one area of the brain to the other,'' he said. ''It is the interconnection between structures.

And in these people, much of it had disappeared. It is possible that the deterioration of the white matter is caused by little strokes.''

Now he is trying to confirm those findings by using an even more advanced technique, magnetic resonance imaging, on the subjects who live in the community.

The health of a patient's muscles and bones is another consideration. Strength is inextricably connected to the ability of the body to balance itself and to proper gait; it can be severely compromised by arthritis and osteoporosis, or deterioration of the bone. But other more subtle changes also come into play.

''Normally, the more you stretch a muscle, the stronger it becomes,'' said Dr. Evan Calkins, director of the division of geriatrics and gerontology at the State University of New York at Buffalo School of Medicine. ''But in older people, as you stretch the muscle maximally, it becomes weaker. So older people tend to walk in a hunched position because the muscle is stronger that way. And they are moving toward a fall.'' Role of Medications

Medications are also believed to contribute to many falls. Dr. Wayne A. Ray, an associate professor at the Vanderbilt University School of Medicine, has demonstrated a connection between hip fractures and psychotropic medicines, which are prescribed to promote sleep, to reduce anxiety and to treat depression and symptoms of dementia.

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Dr. Ray studied 1,021 Medicaid patients in Michigan who had hip fractures in 1981 and 1982, and compared them with 5,606 patients who did not. He found that the users of the medications had twice the risk factor. He later repeated his findings in a non-Medicaid population.

Dr. Ray explained that psychotropic drugs ''produce a residual sedation so the user will feel lethargy, confusion and loss of motor coordination the morning after taking them.''

In addition, some drugs that are used to lower blood pressure can foster postural hypotension, a sudden drop in blood pressure that causes dizziness and fainting.

Perhaps the most comprehensive approach has been taken by Dr. Mary Tinetti, an assistant professor of medicine at the Yale University School of Medicine. Her paper on risk factors was published today in The New England Journal of Medicine.

Like Dr. Wolfson, Dr. Tinetti surveyed two distinct groups of elderly people: nursing home patients in Rochester, N.Y., and community residents in New Haven. In both groups, complete physical, psychological and balance and gait assessements were performed with year-long follow-ups. About one-third of the subjects fell at least once during the project. #9 Risk Factors Among the nursing home residents, Dr. Tinetti found that nine risk factors distinguished people who fell from those who did not: balance and gait, vision, hearing, depression, dementia, back flexibility, postural blood presssure, the number of medications and the need for help with more than two basic daily activities.

''As the number of risk factors increased in any individual, then the chances of falling increased,'' she said. ''We found that none of the people with three or fewer risk factors fell. One-third of those with four to six factors fell, as did 100 percent of those with seven or more.

''We also looked at what the factors were that distinguished those who were injured in falls from those who were not and found that people with weaker lower extremities were more likely to be injured,'' she continued. ''In addition, women were more prone to injury than men, probably because osteoporosis is more common to women.''

In her follow-up study of 336 New Haven residents over the age of 75 who were living independently, she found six risk factors most closely associated with falling: sedative use, dementia or changes in mental status, any disability of the legs, signs of central nervous system disease, balance and gait problems or severe problems in the feet.

She said the researchers also looked at the circumstances of the falls; 10 percent occurred during acute illness and 5 percent while the person was doing something hazardous like standing on a chair. In 44 percent of the falls, something in the environment was a factor. For example, she said, the people tripped on a rug or fell in an area of dim lighting.

Compounding the problem are the attitudes of elderly people.

''The likelihood of falling is modified by what you choose to do or not do,'' said Dr. Stephanie Studenski, an assistant professor of medicine at Duke University who is director of rehabilitation at the Durham Veterans Administration. ''Those who restrict their activities because they feel unsteady may not fall because they don't do anything.'' Impact of Weeks in Bed

But Dr. William J. Evans said the tendency to do nothing can increase the risks. Dr. Evans is chief of the physiology laboratory at the Human Nutrition Research Center on Aging at Tufts University and an authority on strength in the elderly.

''I believe that most fall problems are due to profound muscle weakness from not doing anything,'' he said. ''The focus is to have the institutionalized elderly be as little problem as possible, so in many cases they are put to bed. Two weeks in bed can cause bone loss equal to that of a year in normal aging.''

It may be some time before the researchers find conclusive answers about the causes of falling.

Dr. Nevitt said, ''Though we can identify risk factors and predictors to tell us who will and will not fall, there is a lot of work that remains to be done sorting out what those risk factors mean in terms of cause.'' VULNERABLE PEOPLE

Studies of falls by the elderly are focusing on many factors. BRAIN

Mental changes such as confusion or dementia may increase risk. A new theory implicates deterioriation of white matter under the cortex of the brain, leading to an inability to coordinate vision, the sensations in the inner ear and the feet. CIRCULATORY SYSTEM

Cardiovascular or circulatory problems, especially an inability to adjust blood pressure to sudden changes in posture, can cause fainting and falls. MEDICATIONS

Anti-anxiety drugs, antidepressants and other sedating medications can raise the risk. DISEASES

Effects of diseases, such as the tremors of Parkinson's and the pain of arthritis, can cause falls. MUSCLES AND BONES

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A version of this article appears in print on December 29, 1988, on Page B00009 of the National edition with the headline: HEALTH: Aging; Finally, Doctors Ask if Brutal Falls Need Be a Fact of Life for the Elderly. Order Reprints|Today's Paper|Subscribe